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INCOME VERIFICATION <br />(for Social Security recipients) <br />TO: SOCIAL SECURITY ADMINISTRATION <br />Ladies and Gentlemen: <br />I have applied for a rental unit located in a project with improvements financed by <br />the City of Santa Ana for persons of low income. I hereby give my consent to <br />release to the <br />Specific information is requested below. <br />Date: <br />Social Security No.: <br />Address (Print): <br />Signature: <br />Monthly Benefits Began/Will Begin: <br />Social Security Benefit Amount: <br />Other Benefits): <br />Medicare Deduction: <br />.Are benefits expected to change? Yes <br />If Yes, please state date and amount: <br />Amount: $ <br />Name (Print): <br />Amount: <br />No <br />Date of change: <br />If recipient is not receiving full benefit amount, please indicate reason and date <br />recipient will start receiving full benefit amount: <br />Reason: <br />Date of Resumption: <br />Date: <br />Telephone: <br />Name (Print): <br />Please send form to: <br />Amount :$ <br />Signature <br />Title: <br />Your very early response will be appreciated. <br />Exhibit 1: 9 of 11 <br />